When To Refer to a DBE and Healthcare Provider

When To Refer to A WIC Designated Breastfeeding Expert (DBE)

Basic suggestions for improving the baby’s latch do not resolve the latch issues.
The mother expresses interest in transitioning the baby back to full breastfeeding.
The mother wants to rebuild her milk production.
The mother experiences unresolved sore nipples because of poor latch.
The mother reports issues of recurrent engorgement, plugged ducts, or mastitis.
Other complex infant problems (e.g., managing lactose overload, neonatal abstinence syndrome, neurological issues, cranial defect, etc.) that need assistance with positioning options, breastfeeding aids, basic breastfeeding practices, etc.

The DBE will refer the mother whose baby is compromised to the baby’s healthcare provider if the baby’s weight is affected and for follow-up, treatment, and breastfeeding recommendations.

When a mother and her baby experience breastfeeding challenges, it is important that CPAs and DBEs conduct an assessment to identify potential causes of the mother’s concerns. The DBE will work with the CPA to tailor the mother’s food package to meet the baby’s nutritional needs and provide a feeding plan - which might include appropriate amounts of formula if the mother’s production is not sufficient to provide needed calories.

The DBE may take a more in-depth breastfeeding history to identify potential issues that might be contributing to more complex challenges. The DBE assessment components are more detailed and include but are not limited to:

Breastfeeding history: To identify more details about the mother’s previous and current breastfeeding experiences and potential factors that might affect the current complex issue.
Breast assessment: To learn about any signs and symptoms and concerns of the mother’s breast that might impact milk production or that might reflect the extent of the problem reported.
Infant assessment: To recognize abnormal infant anatomy and inadequate growth.
Feeding assessment: To determine appropriate positioning and latch techniques, milk transfer, feeding pattern, and baby’s behaviors at the breast.

When To Refer to A Healthcare Provider

WIC serves as an adjunct to good health care during critical times of growth and development to prevent the occurrence of health problems and to improve participants' health status. Providing referrals to health care and other services that are outside of WIC's scope helps fulfill this adjunctive role.

The following chart provides examples of when it's important to refer to a healthcare provider. This chart is not exhaustive. Note: Medical problems and management are outside of WIC's scope.

If mom is experiencing:	If baby is experiencing:
A painful “spot” on her nipple or red area(s) on the breast. Or nipple trauma such as cracks, scabs, open wounds, pus, or oozing that may indicate the presence of a breast infection.	Below birth weight by 2 weeks of age. The baby who cannot latch or latches poorly.
Shiny white dot on tip of nipple (bleb) that continues to cause pain.	Concerns about weight loss or at risk for slow/faltered growth pattern. Underweight and/or shows signs of dehydration.
Unusual presentations such as unusual dimpling of the skin or ridges; rashes, itching, and other skin conditions; and distinct lumps.	Certain skin colorings such as yellowish tinge; bluish color; mom’s concerns of baby’s rashes or other skin conditions.
Concerns of mastitis or a breast abscess.	A suspected tongue or lip tie; as well as an unusually large or underdeveloped tongue.
Deep, shooting or stabbing breast pain.	Disinterest in feedings; overly sleepy and not waking to feed (which parents might interpret as a “good” baby); lethargy; apathetic or weak cry; avoiding interacting with the parents.

Fever or flu-like symptoms.

Continued pain or discomfort despite previous tips/suggestions.

Concerns about medications herbal supplements.

Concerns regarding the management and/or appropriate treatment options for identified medical conditions (e.g., polycystic ovary syndrome (PCOS) or undiagnosed or untreated thyroid disorders, GERD, jaundiced, excessive diarrhea, coughing or wheezing, etc.).